Making Decisions about Treatment

from the book How to Have a Baby: Overcoming Infertility
by Dr. Aniruddha Malpani, MD and Dr. Anjali Malpani, MD.

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Discovering that you have a fertility problem can be a difficult process. In addition to the emotional stress you now find yourselves faced with making endless decisions about treatment. The word "decide" comes from a Latin root meaning "to cut away from." Thus decision making, by its very nature, involves loss, giving up one or more options while grasping another. Not deciding maintains the illusion that you can have it both ways - that there is no loss, no risk. Unfortunately, most infertile couples have not learnt to make their own decisions - and not making decisions is one sense the worst possible decision of all! You cannot allow your doctor to make treatment decisions for you either - this can be disastrous as well.

Identifying Your Goals

Most likely, your original goal was to have your own biological child. However, because of your fertility problem, you may be forced to examine your deepest feelings about family, children, and parenting. You could find that you have to re-evaluate your initial plans in order to get the family that you want.

As you work to identify your goals and examine your options, you'll discover that essentially, there are four choices as regards treatment. Depending on the cause and treatability of your infertility, you may need to choose one of the following options:

• To pursue having a biological child with infertility evaluation and treatment
• To try to have a child biologically related to only one parent, either through donor insemination or egg donation
• To adopt a biologically unrelated child
• To decide to remain childless

You may want to rate each of the four options as "desirable," "acceptable," or "unacceptable" at the beginning of your evaluation and periodically re-evaluate these choices.

For some infertile couples, trying to have a biological child and childlessness ( child-free living ) are the only options. For , the switch from having a biologically related child to adopting or having a child biologically related to only one parent may be easier than having no children at all.

Many couples lose track of the fact that their main goal is to be 1parents, even if they can't be biological parents. Therefore, they may pursue infertility treatment for several years and find themselves above the age limit to adopt an infant through an agency. Furthermore, since a woman's fertility decreases after the age of 35, this also decreases the chances of successful treatment. You and your physician should try to take these possible consequences into account when evaluating and choosing your options.

If you are relatively young, there may be a good chance that you will achieve pregnancy without expensive procedures. Therefore you may not wish to explore these as yet. If you are older and have less chances of conceiving , a more aggressive approach might be called for, since time is at a premium.

The decision making process is different for each couple and depends on individual situations and personalities. For example, some couples may opt for expensive high-tech treatments, while others in the same situation will wait to see if they can become pregnant without treatment.

What Kinds of Treatment are Available?

Once you've discussed your infertility with your physician, you'll find that there are a number of treatments available. These include:

• Medication that may be prescribed for either partner to improve fertility
• Surgery to correct an impediment
• In vitro fertilization (IVF) or gamete intrafallopian transfer (GIFT) for patients who require assisted reproductive technologies
• Donor insemination , if male infertility is the problem
• Egg donation , if the female cannot produce eggs
• Surrogate parenting , if the woman has no uterus
• Adoption

Questions You Should Ask Your Doctor

Your doctor may be able to make recommendations about treatment - but there are a number of questions that you should always ask your physician so that you can make the best decision. Unlike other medical questions, infertility recommendations are not always clear. You need to evaluate whether and how well each treatment option will help you reach your goals. Then you'll have to determine which options you will pursue. The following questions may help you build a foundation of medical information to assist you in your decision making process.

• How much will this treatment improve our chances of pregnancy?
• How much risk is involved and what kind of risk is it?
• How long will we have to undergo this treatment in order to give it a reasonable chance to work?
• Will undertaking this treatment eliminate other options?
• How much will the treatment cost?
• Are there other options if this treatment fails?

Your physician can help you determine how much time, physical discomfort, risk, and money will be required for a particular treatment option. You will have to decide how much money you are willing to spend, and how much emotional stress you can take.

You need to design your own fertility treatment plan. Not only will this help you maintain control over your life as you proceed with treatment, it will also help to ensure you get good quality medical care.

Issues Affecting Your Choice

Issues which affect your choice include:

• Medical Factors:
  • Diagnosis ( or lack of one)
  • Quality and availability of medical care
  • Success rate of treatment
  • Level of technology required
     
• Personal Factors:
  • Age
  • Time commitment needed for treatment
  • Personal feelings - physical and emotional
  • Partner's feelings
  • Job and career
  • Financial resources
  • Ethical and religious concerns
  • Family and friends
  • Other obligations and commitments
  • Willingness to change life-styleAggressive or low-key approach to resolution

Each of us has a different personal decision-making style. It is for you to choose which one of the following best fits your own personal style for making medical decisions:

• I prefer to make the final selection of my treatment after seriously considering my doctor's opinion.
   
• I prefer that my doctor make the final decision with regard to which treatment should be resorted to, after seriously considering my opinion.
   
• I prefer to make the final selection about which treatment I will receive on my own.
   
• I prefer to leave all decisions regarding my treatment to my doctor.

It is important to understand that there are no right or wrong styles, and that your style may change as you proceed through diagnosis and treatment. It is imperative that you find a doctor who respects and understands your personal decision-making style.

Just as there are no right or wrong styles, remember that there are no right or wrong decisions about your treatment, and as your options change with time, you may also change your priorities. Counselling may be helpful in setting your priorities - especially if you and your partner disagree on the course of action. As your options change with time, you may also change your priorities . Try to be as realistic and open-minded as possible. While the final outcome will always remain unknown at the time of making decisions, if you take the time and the trouble to make your own decisions, at least you will have the satisfaction of knowing that you tried your best!

In order to make infertility treatments less stressful, you'll need to place time limits on them. Doing this may help you define your goals more clearly. Many couples are willing to accept only two to three years of therapy, because continuing treatment for long periods of time may cause excessive stress.

It is important that you do not lose sight of your relationship with your spouse . Make sure that each of you understands how the other feels about each stage of treatment. Throughout treatment, both of you may encounter times of ambivalence about having children. This is a normal reaction, and you should remember to have realistic expectations of one another.

If reasonable goals are maintained and difficulties and limitations are kept in mind, stress can be minimized. If this is not the case, then a break from treatment, change in plans, or counseling for stress and marital issues may be good idea.

Sometimes, recording information on a worksheet can be helpful. Here is a sample worksheet for making medical decisions about treatment:

Decision (in the rank of choice)

You may want to take each of the options your doctor has suggested, gather the information you need, and go over the options in terms of :

• Time
• Physical and emotional risks
• Cost
• Chances of success, with and without treatment

Also keep in mind how much money and time is needed, what is available and how much you are willing to invest. As you go through this decision-making process, you will probably find that your answers change with time.

If you do not conceive after pursuing your initial plan of treatment for a set period of time, you may need to re-evaluate your goals and options. You may find that you want to discontinue medical intervention, or you may want to seek a different kind of treatment. Keep in mind that it is not at all unusual for partners to have differing views and feelings about infertility and its treatment . Open communication can help both of you to make the best decision.

Facing Treatment

An early step in the entire process is to try and prepare yourself . Ask yourself if it is worth the risk of pursuing treatment without a guarantee of success. Anticipating difficult situations and emotions may help you deal with them more easily.

Your doctor can provide you with information and can refer you to further sources. You can take steps to prepare yourself for what could be a long and frustrating process. But you may also find that as you and your partner work through the stages of infertility treatment, your relationship grows stronger.

Your physician, support groups, other couples who have made similar decisions, and counselors can also provide support and guidance. Above all, remember that with patience, a positive attitude, and the appropriate treatment, most infertile couples can eventually become parents.

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